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Will Your Prescription Meds Be Covered Next Year? Better Check!

NPR Health Blog - Mon, 08/15/2016 - 4:32am
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August 15, 20164:32 AM ET Heard on Morning Edition

Express Scripts assures patients it has a policy of not putting cancer medicine or mental health drugs on the list of products it excludes from its formulary.

Fuse/Getty Images

The battle continues to rage between drug companies that are trying to make as much money as possible and insurers trying to drive down drug prices. And consumers are squarely in the middle.

That's because, increasingly, prescription insurers are threatening to kick drugs off their lists of approved medications if the manufacturers won't give them big discounts.

CVS Caremark and Express Scripts, the biggest prescription insurers, released their 2017 lists of approved drugs this month, and each also has long lists of excluded medications. Some of the drugs newly excluded are prescribed to treat diabetes and hepatitis. The CVS list also excludes some cancer drugs, along with Proventil and Ventolin, commonly prescribed brands of asthma inhalers, while Express Scripts has dropped Orencia, a drug for rheumatoid arthritis.

Such exclusions can take customers by surprise, says Lisa Gill, an editor at Consumer Reports' "Best Buy Drugs."

"We've talked to dozens and dozens of people who find themselves at the pharmacy counter, shocked to find out that the drug is no longer covered," she tells Shots. Patients can appeal the decision in individual cases, but that process can be arduous.

CVS Caremark has been the more aggressive of the two prescription insurers, listing roughly 130 drugs on its "we won't pay" list. Express Scripts lists 85 and has a policy of not banning cancer drugs or mental health medications.

The threat of kicking drugs off their covered lists — which are known as formularies — is a powerful way to drive discounts, says Adam Fein, CEO of the Drug Channels Institute and author of a blog on prescription drug markets.

"Exclusions are one reason why discounts have been growing," he tells Shots.

Express Scripts and CVS Caremark only started actively using their lists this way in 2012. Both firms claim they've already extracted huge savings for their customers: the health insurance companies and private corporations who hire them to manage their prescription drug plans.

CVS says its formulary management will save its customers $9 billion over the next five years.

For 2017, the company has excluded nine drugs that it deems "hyper-inflationary" — defined as "products with egregious cost inflation that have readily available, clinically appropriate and more cost-effective alternatives," says Carolyn Castel, a spokeswoman for CVS Caremark.

The company specifically looks at drugs whose prices more than triple over three years, Castel says.

Those drugs include three skin creams that combine an over-the-counter ingredient, such as hydrocortisone or aloe, with a generic prescription drug to make a new and expensive brand name medication.

CVS manages prescription coverage for about 75 million people. For the first time in 2017 it is dropping from its list two so-called biologic drugs — the diabetes drug Lantus and Neupogen, a medicine commonly given to patients undergoing chemotherapy to help boost white blood cells and immunity. Instead, the company will pay for alternatives known as biosimilars. It was an important move; because of the way these drugs are made, biosimilars aren't exact equivalents of the medications they replace.

But that's part of the strategy of formulary exclusions. The managers of pharmacy benefits pit brand-name drugs that treat the same condition against each other, rather than waiting for generic drugs to come on the market and drive prices down.

Express Scripts covers about 85 million people, according to a recent investor presentation. Spokesman David Whitrap says the company tried to avoid excluding drugs; he recognizes the exclusions are an inconvenience to patients.

"Express Scripts will only ask members to switch their medication if there is a clinically equivalent alternative," he tells Shots, "and only if that switch delivers a significant cost savings for their employer."

For patients, the inconvenience can be minor, or it can be a real medical issue.

"From a consumer standpoint, you can wind up with a much bigger headache, with a lot more time invested in trying to sort out your prescriptions," says Gill.

That's because when the excluded medications don't have generic alternatives that pharmacists can substitute automatically, patients have to go back to their doctor to get a prescription for a new drug.

"It's a tricky trade-off," says Jack Hoadley, a professor and researcher at Georgetown University's Institute for Health Policy. "Am I getting enough of a discount to offset the inconvenience?"

Sometimes the drug on the approved list doesn't work as well for some patients as the one that's been kicked off.

"You end up having to switch to a drug that your prescriber thinks is less than optimal for treating your particular health condition," Hoadley says.

Copyright 2016 NPR. To see more, visit NPR.
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How The Placebo Effect Could Boost An Olympic Performance

NPR Health Blog - Sun, 08/14/2016 - 6:00am

Alexander Naddour, of the U.S. men's gymnastics team, bears the circular mark of cupping on his right arm as he prepares to compete on the pommel horse at the Rio de Janeiro Olympics on August 6.

Alex Livesey/Getty Images

Olympic medals are won by margins of tenths or even hundredths of a second. So, it's no surprise that athletes want any edge they can get — even methods not backed by a lot of scientific evidence.

The alternative practice du jour in Rio, so far, has been cupping. In years past it was special, stretchy tape, said to support sore muscles and improve range of motion. And dietary supplements are an ever-popular option.

Like every other treatment or intervention, though, these purported performance-enhancers are subject to the placebo effect — benefits due to the recipient's belief in a treatment. Not only can placebos improve medical indicators, like pain in people who are sick, they can help athletes go faster, higher and stronger.

"The idea that the placebo effect is manifest in sports performance should not be any surprise at all," says Chris Beedie, a reader in Applied Sport and Exercise Science at Canterbury Christ Church University in the U.K. Even very powerful drugs like morphine work better in people who know they're taking them rather than those who don't, he says. So in the case of illicit drugs like EPO, banned for use in athletes, there's likely some small incremental placebo boost on top of the very real physiological effects.

On the other end of the spectrum, he says, are treatments whose benefits are likely to be entirely or almost entirely due to the placebo effect.

Caffeine falls in the middle of that spectrum — proven to be helpful, but also subject to an extra boost that's based on the belief that it is helpful.

For example, in one small study Beedie and his colleagues published in 2006, cyclists who were told they'd received large doses of caffeine generated a bigger increase in power (relative to their baseline performance) than cyclists who thought they'd received small doses. And those who were told they got a placebo did worse than they did in a baseline test. In fact, none of the cyclists in the study had been given caffeine.

On average, Beedie says, the performance boost from a placebo is in the 2 to 3 percent range. But he cautions that the response will vary depending, on the context. For example, a placebo is likely to work better if you know and trust the person who recommends it.

Katrin Holtwick, of Germany's 2012 beach volleyball team, prepares to serve at the 2012 Olympics in London. Holtwick is bedecked in a stretchy cotton tape widely used by some athletes because they think it supports sore muscles, or improves range of motion.

Alexander Hassenstein/Getty Images

It's not clear how placebos improve performance. It might be that they reduce anxiety, which decreases muscle tension and makes movements more efficient and fluid, Beedie says. Or they could reduce perceived pain or effort.

They may simply motivate you to push yourself more, though Beedie says his lab research has found that indicators of effort — like heart rate — don't go up the way you might expect if the person taking the placebo were working harder.

What's particularly interesting about cupping, he says, is that because it leaves visible signs, it might also put a damper on the performance of competitors who see the marks and suddenly feel they're at a disadvantage.

"I don't know who the first person was to pull off their sweats and show a red blotch, but the race is so often won or lost in that pre-event time," Beedie says, when everyone is focusing and psyching each other out. (Just look at what went on in the ready room before the swimming semifinal featuring rivals Michael Phelps and South Africa's Chad le Clos, when Le Clos' "get loose" dance provoked a steady scowl from Phelps.)

"It's a fantastic example of how sport, despite all the science and technology, is still at heart a very ritualistic thing," says Beedie.

So assuming that a treatment has no proof of actual benefit but isn't likely to hurt an athlete, is there anything wrong with benefiting from the placebo effect?

For individual competitors, maybe not, says Timothy Caulfield, a professor in the faculty of law and school of public health at the University of Alberta and the author of Is Gwyneth Paltrow Wrong About Everything? When Celebrity Culture and Science Clash. He recently compiled a list of performance aids that, though popular, have little or no evidence to back up their use.

Caulfield says he is concerned that seeing big-name Olympians advocating unproven treatments "has the potential to legitimize the pseudoscience." And that could influence how we mortals spend our limited resources – pushing us to buy things that aren't actually helping us solve our own problems.

Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She's on Twitter: @katherinehobson

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Psychiatrists Reminded To Refrain From Armchair Analysis Of Public Figures

NPR Health Blog - Sat, 08/13/2016 - 6:00am

A poll of psychiatrists about the mental fitness of Barry Goldwater, Republican nominee for president in 1964, led to the creation of a rule that discourages doctors from public diagnoses.

William Lovelace/Hulton Archive/Getty Images

Earlier this week the American Psychiatric Association cautioned psychiatrists against taking part in a feverish new national hobby.

Catching Pokémon wasn't mentioned. Psychoanalyzing Donald Trump was.

On the organization's website, APA President Maria A. Oquendo wrote: "The unique atmosphere of this year's election cycle may lead some to want to psychoanalyze the candidates, but to do so would not only be unethical, it would be irresponsible."

Oquendo was referring to the "Goldwater Rule," a guideline adopted by the APA after a 1964 survey of psychiatrists found that nearly half of those polled felt that GOP presidential candidate Barry Goldwater was psychologically unfit to be president.

The rule states that despite the shiny diagnostic T-ball Trump has propped in front of them — his volatility, his grandiosity, his entitlement — professional code holds that if they haven't performed an in-person evaluation, psychiatrists should keep quiet on the mental character of public figures (unless of course they have that person's permission to speak out).

The professionalism is sound. But what happens when, in the minds of many, a candidate crosses the line?

The Goldwater Rule

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry

On Tuesday of this week, at rally in Wilmington, N.C., Trump suggested that perhaps there is something gun owners — or, "the Second Amendment people" — can do if Hillary Clinton is elected and appoints judges who oppose gun rights. Though he didn't specify just what they could do, the implication was ominous.

A few months ago, speaking about nuclear weapons, he reportedly asked a senior foreign policy adviser, "If we have them, why can't we use them?"

One could argue that a presidential candidate casually evoking the possibility of nuclear war — even if joking — could be seen as crossing a line.

Many mental health specialists feel that short of saddling politicians with formal diagnoses, we still need a realistic way to assess and discuss their mental states. In his recent cover story for The Atlantic, Dan McAdams, a psychology professor at Northwestern, did just that.

McAdams used scientifically backed personality and social psychology research to develop what he calls a "psychological commentary" on the life and the personality of Trump. It's a reasoned, rational account of a hulking persona: careful to avoid a specific diagnosis. McAdams simply concludes that the Republican candidate has "narcissistic motivations and a complementary personal narrative about winning at any cost."

"These constructs give you a richer understanding of his life and personality than you might get from, say, offering a clinical diagnosis," McAdams told me in an email.

Tufts psychiatrist Nassir Ghaemi agrees that mental assessments can be important, whether by psychiatrists, psychologists or other mental health professionals: "I think in principle [this] kind of detailed psychological analysis can be legitimate, and certainly shouldn't be verboten for being unethical." Yet, he says, objectivity and a scientific rationale are key, as opposed to what he considers catchphrases rooted in Freudian jargon. The media's frequent verdict on Trump's "narcissism" especially bugs him.

Ghaemi also proposes a few amendments to the Goldwater Rule. He believes that the in-person examination requirement should be nixed — assessing psychiatric patients often requires outside input: from colleagues; from family; from friends — and he also feels that psychiatrists should be able to weigh in when a candidate poses a societal threat that overtakes professional oath.

Still, Ghaemi, McAdams and the other mental health experts I interviewed in reporting this piece all staunchly advise against diagnosing public figures from afar — armchair psychiatry, they feel, is a great irresponsibility.

But many also feel that even in the absence of a diagnosis, the more general psychological interpretations common to cable news and other media outlets — not under the rubric of the Goldwater Rule, psychologists show up with exceptional frequency as talking heads — can be ethically dubious.

After a series of statements by Donald Trump drew fire, the president of the American Psychiatric Association cautioned members that publicly psychoanalyzing candidates is unethical and irresponsible.

Evan Vucci/AP

"I think offering semi-psychological interpretations is a poor idea for psychologists and psychiatrists," said Arthur Caplan, a bioethicist at New York University's Langone Medical Center. "How can anyone give an in-depth character analysis on psychological or mental health grounds without knowing or examining the person at all?"

Caplan feels doing so not only stirs up gossip — gossip that demeans those suffering from diagnosed mental illness — but risks pathologizing what could be normal, if off-putting, personality traits. "Positions or attitudes that are outside of the mainstream or outside the pale can be ascribed to mental illness, when in fact there are plenty of racist, sexist, classist bigots all over the place who are not mentally ill," he said.

Insight into the health of our politicians has been a campaign concern, well, probably forever.

But a few recent examples come to mind. FDR had a deal with the press corps to cover up the extent of his paralysis. John F. Kennedy's Addison's disease, a disorder of the adrenal glands, was cleverly concealed until after he was elected. President Eisenhower, after being hospitalized for a heart attack, was red-faced when his doctors publicly applauded his first "good bowel movement."

The voluntary release of select physical health data has since become commonplace among presidential candidates. President Obama's enviable blood pressure is one thing. Unfortunately, mental health is another. Stigma still runs deep.

In her statement on behalf of the APA, Oquendo makes clear her strong support for the Goldwater Rule. She — and Caplan for that matter — also feel the guidance should apply not just to psychiatrists but to psychologists and other mental health practitioners as well.

One reason that Oquendo is resolute in pointing this out is that plenty of people with mental illness attain great success: CEOs, performers and even psychiatrists.

"Whether we like it or not, many have the notion that an individual with a psychiatric condition is less capable than others," she laments. "The fact is that's simply not true."

Ghaemi has written extensively on how mental illness can positively contribute to character and success in many ways, whether it's the empathy and realism sometimes imparted by depression (Lincoln, Gandhi and Martin Luther King Jr. come to mind) or the ambition and creativity brought on by mania. A 2006 study out of Duke University reviewed the historical records of 37 presidents and concluded that 18 of them met criteria of psychiatric diagnoses.

One idea occasionally floated through the psychiatry community is instituting a mandatory mental and physical health screen for aspiring presidents, the results of which would be made public.

In 2008, for example, a panel of high-level health experts recommended that both presidential and vice presidential candidates be required to undergo a health screen by an independent team of doctors. To this end, Ghaemi argues that if someone is in a position to send our sons and daughters into war, we deserve a more in-depth glimpse into his or her psyche — one interpreted and presented to the public by mental health experts.

"I've been arguing for a presidential health screen for over 20 years!" said Caplan, laughing. "But I see it as a panel that simply provides information for the public to assess, not one that qualifies or disqualifies anyone. If you want to vote for FDR with polio or Reagan with incipient Alzheimer's, you should be able to."

However, much like the 2008 recommendation, Caplan's efforts, he admits, have gone nowhere.

Oquendo is not sold on a standardized mental health screen, pointing out that upwards of 20 percent of the population experiences mental illness in a given year — and also that a public screen could bolster the erroneous notion that having a psychiatric condition renders someone an unfit candidate.

So assuming no screening process is implemented anytime soon — and also that asserting psychiatric absolutes remotely is probably irresponsible and ultimately unhelpful — how are we to assess the mental character and capacities of our candidates?

According to Oquendo, the answer is simple: behavior.

"So many factors can influence behavior. And, for example, not everyone with bipolar will be overly creative or ambitious, so you can't predict somebody's behavior just based on diagnosis," she explains. "But how someone acts is right there for people to see; voters can then decide if a particular behavior is acceptable or not."

In other words, the cause of someone's conduct — whether mental illness or not — is beside the point.

Bret Stetka is a writer based in New York and an editorial director at Medscape. His work has appeared in Wired, Scientific American and on The He graduated from University of Virginia School of Medicine in 2005. He's also on Twitter:@BretStetka

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Why Doctors Want A Computerized Assistant For Cancer Care

NPR Health Blog - Fri, 08/12/2016 - 12:35pm

Researchers at the New York Genome Center are working with IBM Watson to make better treatment plans for cancer patients.

Courtesy of New York Genome Center

A computer may soon be able to offer highly personalized treatment suggestions for cancer patients based on the specifics of their cases and the full sweep of the most relevant scientific research.

IBM and the New York Genome Center, a consortium of medical research institutions in New York City, are collaborating on a project to speed up cancer diagnoses and treatment.

The work, which got underway in 2013, is exploring the use of computers to help analyze a wide range of genetic information and the scientific literature with the goal of quickly formulating precise treatment plans for cancer patients.

The line of research is being orchestrated by Robert Darnell, the founding director of the New York Genome Center and a neuro-oncologist at Rockefeller University. A project on brain tumors aims to bring cancer experts in New York City to bear on treatment plans that take advantage of the very latest scientific evidence.

An essential assistant on Darnell's team is supercomputer IBM Watson, which helps by comparing the genetic differences between healthy cells and tumor cells in patients, as well as fetching the newest treatment ideas from medical journals.

Watson wasn't always part of Darnell's lineup. When he started the project, he relied on the collective brainpower of a bunch of medical researchers in New York City. Fifteen of them, including Darnell, spent three weeks evaluating the case of the first patient of the project. But, he says, "by the time we got through with this patient, the patient died."

Speed matters, given how fast cancer can spread. Information overload is a particular challenge.

"Cancer is not giving you the luxury of time," says Ajay Royyuru, the director of IBM's Healthcare and Life Sciences Research. And, he adds, there are "more papers published in each year than cancer researchers can read and remember."

New York Genome Center Center has more DNA sequencing capacity than any other single institution in New York City.

Courtesy of New York Genome Center

In contrast, IBM's supercomputer Watson, famous for defeating former champions in Jeopardy! in 2011, is able to read "800 million pages per second ... from medical literature to patient records to doctors' notes," according to Christine Douglass at IBM Watson Health.

Upon learning about Watson's abilities, Darnell approached IBM. By 2014, a human-computer coalition to fight cancer was born.

"Compare what the genetics in the healthy cell looks like to what the genetics in the cancer cell looks like, you get the list of differences," says Steve Harvey, vice president of Watson Health at IBM. "Watson will first try to figure out what are the differences that could be causing cancer. For each of those potential genetic issues, it will go through databases and literature to find" known treatment options, he says.

With the help of Watson, Darnell's group studied 30 patients with glioblastoma, an aggressive form of brain cancer, and developed personalized treatment options for each patient "based on genetic mutations present in the tumor," according to Darnell. Darnell declined to comment on the specifics of the findings before they're published. But, he says, "there are patients who will benefit" from this study. A preliminary report on the findings has been submitted to The Journal of Clinical Oncology.

Both IBM and the New York Genome Center are moving on to find out whether Watson can apply what he learned from Darnell's research to a larger group of glioblastoma patients.

"We'll be working with the Veterans Health Administration," says Harvey. According to Harvey, "The VHA overseas the largest population of cancer patients — 3.5 percent of all cancer patients in the US are from the VHA."

According to Darnell, the paper his group submitted will "lay the groundwork for the larger, more comprehensive paper on the same study." Darnell says the current research project is not yet a clinical trial, and he hopes to execute a large-scale clinical trial in the future, recruiting "any cancer patient who is sick, not necessarily from glioblastoma."

"It's not going to be doable without the machines," says Darnell.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Where Lead Lurks And Why Even Small Amounts Matter

NPR Health Blog - Fri, 08/12/2016 - 4:40am
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August 12, 20164:40 AM ET Heard on Morning Edition Katherine Du for NPR

Lead problems with the water in Flint, Mich., have prompted people across the country to ask whether they or their families have been exposed to the toxic metal in their drinking water, too.

When it comes to assessing the risk, it's important to look in the right places.

Even when municipal water systems' lead levels are considered perfectly fine by federal standards, the metal can leach into tap water from lead plumbing.

Kate Gilles moved to Washington, D.C., from Rhode Island for a job in international public health six years ago. When she was pregnant with her son, now 3, and her daughter, who turned 1 in July, she says she paid close attention to her health.

She ate better. She exercised. She followed her doctor's orders. Gilles checked off every task on the long list of things that she was supposed to do to help protect her babies.

But that was before Flint, and it never occurred to her to test her drinking water for lead.

No one — not her pediatrician, not authorities at her local water utility and not the realtor who sold her the home she lives in — suggested that she might have a problem with lead.

In April, she learned that her home is one of more than an estimated 6 million in America that gets its water delivered through a lead service line.

When There's Lead Underground

When there is a problem with lead in drinking water, service lines are the most likely culprit. Service lines are like tiny straws that carry water from a utility's water main, usually running below the street, to each building.

In older cities, many of them in the Midwest and Northeast, these service lines can be made of pure lead.

Katherine Du for NPR

Wherever lead service lines are in place, there is a risk of water contamination. The toxic metal can leach into the water whenever something jostles the pipes, like nearby construction, a heavy truck coming down the road or when the water just sits still for too long.

Civil engineer Marc Edwards, the Virginia Tech professor who helped document the lead problems with water in Flint, calls lead service lines "ticking time bombs."

The Risks Of Low-Level Lead Exposure

Dr. Bruce Lanphear has spent decades researching low-level lead exposure, and his work is often cited by the Centers for Disease Control and Prevention. He says that while blood lead levels have been reduced drastically in recent decades, even levels as low as 5 micrograms per deciliter can lower IQs and increase the risk of attention and behavioral problems in children. For adults, lead exposure can cause kidney problems and high blood pressure.

Because it would be unethical to expose people to a known toxin, clear data are lacking on exactly how much lead a person must be exposed to before it shows up in the blood or triggers health and behavioral problems. Public health officials say that removing all lead from a person's environment is the best course of action.

Wherever lead service lines or other lead plumbing fixtures exist, there are precautions people can take to protect themselves — if they know they are at risk. They can flush their pipes every morning. They can purchase a filter certified for lead removal. Ultimately, they can replace lead service lines and lead plumbing in the house, though those replacements can be costly.

Still, there aren't any federal notification laws for the presence of lead plumbing as there are for lead paint. Checking the service line isn't part of typical home inspections. Landlords aren't required to warn tenants about lead pipes, and realtors don't need to tell potential buyers.

Gilles, who has a master's degree in public health, said she felt silly for not looking into lead risks from pipes. "But I also feel really angry that there's nothing that flags it for homeowners," she says.

Lead Regulations: 'Illusion Of Safety' Or Protection?

After learning that her house has lead pipes, she ordered a test kit from DC Water, the local authority. When she got the results, she was more confused than relieved. The test showed 0.7 parts per billion of lead in the water, far below the EPA's so-called action level, set at 15 parts per billion.

But what did the results mean? "I'm marveling at the total lack of lucidity of this letter," she says. "Because it doesn't say whether or not we need to be concerned. I'm guessing that the EPA decided that the margin of safety was this 15 parts per billion, and we're under that."

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Except that isn't at all what the EPA decided.

The EPA seeks to control lead in the drinking water with its Lead and Copper Rule, created in 1991. The rule says that, depending on factors like how big a city is and how long it has been since high lead levels were last detected, water utilities have to test the water in between 50 and 100 homes with lead service lines every six months to nine years.

If 90 percent of homes have lead below the 15 parts per billion action level, the water utility passes the test. Nothing has to change. If the utility fails the test, it has to take follow-up action, including more testing and possibly changing water treatment methods.

But, critics say, there are several problems with the EPA's rule. For one, the most severe cases are essentially tossed out of the utilities' reports.

Also, according to the EPA's own research, the current lead sampling protocol requires water be collected immediately after the water has been stagnant for six hours. That means they are likely capturing the water that has been sitting inside the house, rather than the water that has been sitting in the lead service line. In other words, the utilities aren't capturing the full extent of the problem.

In addition, critics say, the EPA's trigger for action — or so-called action level — is set too high, at 15 parts per billion of lead in the water. Too many test results above that threshold are a red flag for water utilities, a sign that they might have a lead problem.

The number is often cited as a threshold for public health, but no amount of lead is considered safe for human consumption.

Jeff Cohen helped develop the EPA's Lead and Copper Rule back in the late '80s. He says that the action level didn't come from medical research; it came from water utilities.

"It was based on the little data that was available at that time from water utilities in the U.S. that had installed different levels of corrosion control treatment," he says.

Cohen points to the goal written into the rule, which is zero lead in drinking water. The action level, he says, is "not really designed to identify a safe level of lead in drinking water. It's simply one of many pieces of data that should be used to determine whether corrosion control treatment is working or not."

In June, the American Academy of Pediatrics called on federal regulators to tighten lead oversight, including lowering the action level. The Academy claimed that lead thresholds are set too high, they aren't based on science, and they create an "illusion of safety." Dr. Lanphear was the lead author on the AAP policy.

"We've consistently said that no level of lead is safe," says Joel Beauvias, the deputy assistant administrator for the EPA's Office of Water. He said that the 15 parts per billion action level isn't meant to be a threshold for public health.

The Safe Drinking Water Act says that the rule has to be updated every six years. The agency has been discussing possible revisions since 2010 and is looking at making improvements to the rule. But an agency spokesperson said it is too early to speculate on exactly what the agency will propose or when.

While the ultimate fix would be to replace all lead service lines and lead plumbing, that's a daunting task. In the meantime, there is a call for greater transparency about where lead service lines are in use so that people can reduce their risks.

The EPA wrote governors in February across the country encouraging, but not requiring, disclosure.

After multiple inquiries from NPR, D.C.'s water utility published a map of the lead service lines it knows about. The map is incomplete; there are more than 13,000 homes on the map that may or may not have lead pipes. Still, the map gives residents — particularly renters — easier access to the utility's records. In most cities, the information is still considered private and available only to the person paying the water bill.

George Hawkins, the general manager for DC Water, said it is in everyone's best interest to make lead service line inventories public. The information helps homeowners manage risks in the short term and can encourage them to replace lead service lines.

Although lead levels have gone down significantly in D.C. since the 2004 crisis, the majority of homes the utility has tested in recent years have still shown small amounts of lead in the water — 1 or 2 parts per billion.

Hawkins says that might be a problem for certain households. "Were I [in] a household with a wife who was pregnant or small children, I'd want that number at zero or as close to zero as it can be," Hawkins said.

Gillis decided that even small amounts of sporadic lead release weren't OK for her two children. She and her husband decided to have their lead service line replaced in May. It cost them $1,400.

She's had both of her children tested for lead and is reassured by the results. But she's still angry that no one told her about the lead service line — or the potential risk — earlier.

"The argument can be made that the onus was on us," she says. "But we didn't even know to look at it. This should really be the duty, the responsibility of the government."

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Talk About An Ancient Mariner! Greenland Shark Is At Least 272 Years Old

NPR Health Blog - Thu, 08/11/2016 - 2:03pm
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August 11, 20162:03 PM ET Heard on All Things Considered

The long lifespan of the Greenland shark, shown here in the cold, deep waters of the Uummannaq Fjord, may only be surpassed by that of the ocean quahog, a clam known to live as long as 507 years.

Julius Nielsen/Science

Sharks can live to be at least 272 years old in the Arctic seas, and scientists say one recently caught shark may have lived as long as 512 years.

That's according to a study published Thursday in the journal Science that says Greenland sharks can live longer than any other known animal advanced enough to have a backbone. Until now, the record-holder for the oldest vertebrate was the bowhead whale, known to have lived up to 211 years.

The Greenland shark, a massive carnivore that can be more than 16 feet long, hasn't been studied much, and its life in the cold northern waters remains largely mysterious. Julius Nielsen, at the University of Copenhagen in Denmark, says there had been some hints that Greenland sharks grow very slowly, perhaps less than a centimeter per year. That suggested the huge sharks might be ancient.

"We only expected that the sharks might be very old," says Nielsen. "But we did not know in advance. And it was, of course, a very big surprise to learn that it was actually the oldest vertebrate animal."

He and some colleagues obtained 28 female Greenland sharks taken by research vessels as unintended bycatch from 2010 to 2013. The researchers then used radiocarbon dating techniques on the lenses of the sharks' eyes.

A Greenland shark caught as bycatch from research vessel Pâmiut in southwest Greenland.

Julius Nielsen/Science

There's a bit of uncertainty associated with the age estimates, but Nielsen says the most likely age for the oldest shark they found was about 390 years. "It was, with 95 percent certainty, between 272 and 512 years old," he says. The researchers believe these sharks reach sexual maturity at about the age of 150 years.

"It's a fascinating paper and certainly moves back the vertebrate longevity record by a substantial amount," says Steven Austad, who studies the biology of aging at the University of Alabama, Birmingham. "Even if you look at the low end of their estimate — 272 years — that's still substantially longer than any other documented vertebrate."

He says there are lots of anecdotal accounts of long-lived turtles and fish, but this beats those by a long shot.

The Greenland shark's lifespan may really only be surpassed by that of the ocean quahog. These clams have annual growth rings on their shell, and scientists have found that they can live as long as 507 years.

The Greenland shark, the bowhead whale and the oldest ocean quahogs spend their long lives in cold northern waters, notes Austad, suggesting that low temperatures might have something to do with their unusual longevity.

"I don't think that cold is the whole story," says Austad. "It's probably playing a role. But my guess is there are plenty of short-lived animals that are swimming around with this shark."

Still, he says, just imagine what it would be like to have muscles, like these sharks, that have been working nonstop since the time of the Pilgrims.

"There's something going on in those muscles that we'd very much like to know about," says Austad.

He notes that Greenland sharks would not be easy to study in the lab, but perhaps people could study shark cells grown in a dish.

"Probably whatever sort of physiological tricks the sharks have to live that long, and the quahogs have to live that long, they're probably something that humans don't have," says Austad. "But it's something that, if we discover what it is, we might be able to adapt it to human use."

He's been studying the quahog, which has a beating heart, and whenever doctors who specialize in geriatrics stop by, he likes to hand them a 200-and-something-year-old clam and tell them they're holding a beating heart that's older than any heart they'll encounter in their entire career.

Copyright 2016 NPR. To see more, visit NPR.
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How Weight Training Can Help Women Stay Strong

NPR Health Blog - Thu, 08/11/2016 - 11:30am

Try it, you'll like it.

Sally Anscombe/Getty Images

For years I was a totally lopsided exerciser.

I did aerobic workouts until the cows came home, easily meeting the government's recommendation of 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity exercise per week. But I rarely picked up a dumbbell or did a pushup. I definitely didn't follow the government's advice to work out all my major muscle groups with resistance training at least twice a week.

Bicep Curl

The Centers for Disease Control and Prevention recommends using a weight that feels challenging after 10 repetitions.

Source: CDC

Credit: Meredith Rizzo/NPR

I wasn't the only one falling short on that front. Federal data show that, overall, adults do a much better job of meeting the requirements for aerobic activity than both aerobic and strength training.

That discrepancy is more pronounced among women. Among women ages 25 to 64, for example, 49 percent report getting the recommended amount of aerobic exercise, while just 18 percent report meeting the guidelines for both types of exercise. Among men in the same age range, those figures were 53 percent and 25 percent.

That's too bad. There's evidence that both types of exercise have many common benefits, such as a lowered risk of Type 2 diabetes, says Stuart Phillips, a professor of kinesiology at McMaster University in Hamilton, Ontario. But he says that only resistance training — or possibly heavier, weight-bearing aerobic exercise — seems to alleviate the risk of osteoporosis.

Keeping up muscle mass as you age also helps you keep up the activities of everyday life and prevents injuries when you're older. "If you can maintain or preserve some of that muscle mass, your risk of sarcopenia is lower, and we believe there's a lower risk of falling and fracturing bones," says Roger Fielding, director and senior scientist of the Nutrition, Exercise Physiology and Sarcopenia Laboratory at Tufts University's Jean Mayer USDA Human Nutrition Research Center on Aging.

Toe Lift

This move works your calves, lower legs and ankles. Push up on the balls of your feet, hold it for two seconds, then return to the floor.

Source: CDC

Credit: Meredith Rizzo/NPR

Women outlive men, on average, but often spend their final years in institutional care because of their inability to perform those basic tasks and live independently, says Phillips. (If that long-term motivation isn't enough, consider the effects it may have on your current exercise routine. Research suggests strength training can improve running economy in high-level athletes, for example.)

So how do you actually start a strength-training program? There are a ton of online resources with sample workouts for beginners. You can also take advantage of a free one-time walkthrough at a local gym or YMCA to help get the lay of the land, says Jacque Crockford, an exercise physiologist with the American Council on Exercise and spokesperson for the group.

The U.S. government's recommendation is for two full-body sessions a week; Phillips says three times a week is even better. After that, returns tend to diminish. And his own research suggests that the debate over whether the ideal is fewer reps of heavier weights or more reps of lighter weights may be overdone. "It probably matters very little what type of weight, very heavy or light, as long as you lift to a point where you'd grade the effort you're putting in at 8 or 9 out of 10," he says.

Crockford says for general muscular fitness, one to two sets of 12-15 reps with a weight that feels challenging at the end is a good rule of thumb.

One benefit that may be overlooked is how resistance training makes you feel. When I finally did start lifting regularly, I noticed how satisfying it was to be able to carry my groceries more easily or lift a UPS package with the "heavy" sticker on it. The experts I spoke with say that is common. Crockford says: "There's a confidence and independence that comes from being stronger."

Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She's on Twitter: @katherinehobson.

Copyright 2016 NPR. To see more, visit NPR.
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In Battle Of Health Care Titans, Should Insurers Act Like Wal-Mart?

NPR Health Blog - Thu, 08/11/2016 - 10:29am
Lorenzo Gritti for NPR

Retail giant Wal-Mart uses its market dominance to inflict "ruthless," "brutal" and "relentless" pressure on prices charged by suppliers, business writers frequently report.

What if huge health insurance companies could push down prices charged by hospitals and doctors in the same way?

The idea is getting new attention as already painful health costs accelerate and major medical insurers seek to merge into three enormous firms.

Now that hospitals have themselves combined, in many cases, into companies that dominate their communities, insurance executives argue the only way to fight bigness is bigness.

No. 2 health insurer Anthem's proposed marriage to No. 6 Cigna would let the combined company "manage the cost drivers that negatively impact affordability for consumers," Anthem CEO Joseph Swedish told Congress last year. The bigger company could "negotiate better reimbursement rates" with medical providers, says Anthem spokeswoman Jill Becher.

In metro areas with only a few big insurers, hospital and doctor bills tend to be lower than economists would otherwise expect. If only one or two insurers are bidding to include providers in their networks, hospitals and doctors must submit to the offered deal or risk getting shut out of a huge piece of business.

"There's some literature out there that does show that when you have relatively concentrated insurance markets, they tend to keep actual hospital costs down," said Yevgeniy Feyman, a researcher at Harvard T.H. Chan School of Public Health and a fellow with the Manhattan Institute.

The American Hospital Association as well as the American Medical Association, trade groups for hospitals and doctors respectively, have long worried that insurance mergers do just that. Now that Anthem is trying to buy Cigna, and No. 3 health insurer Aetna wants to buy No. 5 Humana, they're even more concerned.

Both deals "have the very real potential to reduce competition substantially" and "diminish the insurers' willingness to be innovative partners with providers and consumers," AHA lawyer Melinda Reid Hatton wrote to antitrust authorities after the combos were announced.

But hospitals have built their own market power through numerous mergers, giving them broad ability to raise prices paid by employers, taxpayers and consumers beyond what a competitive market would allow, economists argue.

Hospitals "are much more concentrated than insurance markets," said Glenn Melnick, a health care economist at the University of Southern California who has researched the subject. "They face a lot less competition than the [health] plans do."

Why not give hospital giants somebody their own size to negotiate with?

For one thing, insurers might just pocket higher profits from low provider prices instead of passing the savings to consumers and employers.

"I don't find any evidence that reduction in provider payment leads to reduction in insurance premiums, and I don't know of any study that does," said Leemore Dafny, an expert in insurance markets and an economist at Harvard Business School.

Feyman suggests requiring insurers in concentrated areas to spend 90 percent of their revenue on medical care. That might reduce their ability to boost profits with premium increases while preserving their ability to hold down hospital and doctor costs, he said.

But he sees such a measure as only a "worst-case scenario" for the most monopolized insurance markets, not a recipe to allow the Anthem and Aetna deals to go through.

Antitrust regulators are siding with the hospitals and doctors.

In late July, the Justice Department sued to block both insurance mergers, arguing that competition is important to keep premiums down and that the deals "would leave much of the multitrillion-dollar health insurance industry in the hands of three mammoth insurance companies."

They also rejected the Wal-Mart argument, which is related to what economists call "monopsony," a concentration of buying power.

Monopsony is the opposite of monopoly: Instead of using market dominance to raise prices for consumers, huge buyers force down prices from suppliers. Wal-Mart is often described as holding monopsony-like power.

But critics of the insurance deals say monopsony can go too far. If the buyer pushes prices too low, suppliers stop producing, making needed goods and services unavailable.

"As a result of the merger, Anthem likely would reduce the rates that ... providers earn by providing medical care to their patients," the Justice Department argued. "This reduction in reimbursement rates likely would lead to a reduction in consumers' access to medical care."

Accepting Wal-Mart logic for health care might bolster arguments for an even bigger, more powerful buyer of medical services: the government.

A single-payer, government health system, of the type advocated by Democratic presidential candidate Bernie Sanders, would be the ultimate monopsony: one buyer, negotiating or dictating prices for everybody.

Neither the hospitals nor the insurance companies want that.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Neither of them is affiliated with health insurer Kaiser Permanente. You can follow Jay Hancock on Twitter: @jayhancock1

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Robot-Like Machines Helped People With Spinal Injuries Regain Function

NPR Health Blog - Thu, 08/11/2016 - 9:00am

Scientists with the international scientific collaboration known as the "Walk Again Project" use noninvasive brain-machine interfaces in their efforts to reawaken damaged fibers in the spinal cord.

AASDAP and Lente Viva Filmes, São Paulo, Brazil/Nature

Researchers in Brazil who are trying to help people with spine injuries gain mobility have made a surprising discovery: Injured people doing brain training while interacting with robot-like machines were able to regain some sensation and movement.

The findings, published in Scientific Reports (one of the Nature journals), suggest that damaged spinal tissue in some people with paraplegia can be retrained to a certain extent — somewhat the way certain people can regain some brain function following stroke though repetition and practice. In fact, this isn't a new idea for treating injuries of the spinal cord. Even people with severe injuries can regain some sensation and function through physical therapy if some nerve fibers remain.

The eight paralyzed people in the Brazilian study didn't regain enough mobility to support their own weight on their legs, but Dr. Miguel Nicolelis, a neuroscientist and physician with Duke University who led the research, says his experimental subjects did make "partial recovery" — improvements that significantly helped their quality of life. They had better control of bowel and bladder functions, he says. Some men were able to have erections and one woman decided to deliver a baby vaginally. "She could feel the baby for the first time," he says. "She could feel the contractions."

The patients in Nicolelis' study have paraplegia, and still can't support their own weight. But they can learn to control this machine with their brain, which gives them rich tactile feedback with each step.


The study of the first 12 months of training didn't document the most dramatic quality-of-life improvements that Nicolelis announced in a telephone briefing with reporters. But it did describe some of the improvements in sensation and movement.

Nicolelis previously garnered worldwide publicity for his work by arranging for one of his patients to kick out a ceremonial soccer ball during the World Cup tournament in Rio de Janeiro in 2014. The build-up for that moment was more dramatic than the actual event. But it did highlight Nicolelis' ambitious efforts to help people with paralysis improve their mobility through robotics, through an international scientific collaboration known as the Walk Again Project.

Other research groups are pursuing similar strategies, and there are several products on the market that help people with spinal cord injuries to walk.

In his work, Nicolelis and his team trained people with paraplegia to visualize moving their muscles, by having them wear virtual reality goggles and giving them tactile feedback on their arms. The idea was to create brain signals that could be picked up by electrodes and used to control the bulky robotic apparatus. Nicolelis was surprised to see that, as people improved their ability to visualize limb movements, they were also regaining some feeling and movement as well.

His patients had been paralyzed for three to 13 years.

"For the first time in many years they were able to voluntarily control their muscles," he says. "They could move their legs or contract muscles under voluntary control." Some people had their level of paralysis upgraded to a less severe rating of "incomplete paraplegia."

"This has not been seen before," he says. "I call this an important milestone."

But Edelle Field-Fote, director of spinal cord injury research at the Shepherd Center at Emory University, wasn't so rhapsodic. "I would not say it's unprecedented," she tells Shots. "I'd say the intervention [used in Brazil] is unprecedented."

Nicolelis' therapy involves not just the virtual-reality training; it includes physical therapy and extensive stimulation as the robotic machines move their muscles. "If you gave anybody [with some remaining spinal cord] 12 months of therapy, you'd see improvement," Field-Fote says, even years after an injury.

She notes that at the outset of the study, all the participants had some ability to walk — with assistance from crutches, walkers, braces and in some cases human attendants.

"If you exercise with the body-weight support and treadmill training, you also get improvements," says Monica Perez, a scientist at the Miami Project to Cure Paralysis who studies mechanisms involved in the control of human movement.

"The question is whether this is superior to previous approaches and which are the mechanisms," Perez says. "This was a long period of training, so it's hard to compare."

The findings from Brazil raise the possibility that more prolonged efforts to restore some movement in paralyzed people could pay off.

"Overall, the study is plausible and interesting," says Dr. Lyn Jakeman, a neuroscientist who oversees extramural research on spinal cord injury for the National Institute of Neurological Disorders and Stroke. But she also notes that the participants had so many different interventions, it's not entirely clear whether the visualization exercises or some other combination of factors was responsible for the reported effects. And the study had no control group for comparison.

These independent experts couldn't evaluate the claims Nicolelis made in his press call but didn't include in his published report.

Part of the training in Miguel Nicolelis' research involves having a patient with spinal cord damage learn to use an avatar to walk in virtual reality, while being given visual and tactile feedback.

AASDAP/ Lente Viva Filmes/Nature

Nicolelis tells reporters that two women in his study who had been paralyzed for more than a decade showed the most improvement. They "can generate leg movements, move their legs out and in and flex their knees," he says. Some of that is captured in a video he released with the published study.

"They are continuously improving," he says, beyond what he reports in his peer-reviewed paper. One woman now has enough mobility to get out and about, Nicolelis said. "Now she can sit [and] she can basically drive."

Nicolelis says it's possible that people with even weak muscles in their legs can more easily control the robotic machinery that he and his collaborators are developing. He suspects that residual nerve fibers through the spinal injury are able to carry sensations up to the brain, along with some rudimentary commands from the brain down to the muscles.

Other researchers internationally are pursuing several different approaches to treating spinal injuries. Those include drugs to limit the damage caused by an injury, along with various approaches to cell transplantation, as well as electrical stimulation and efforts to retrain the central nervous system.

There are roughly 25 million people worldwide with severe spinal injuries. Nicolelis acknowledges that his experiments have been expensive. But if the virtual reality training is indeed key to the improvements he has documented, that could be the basis of less expensive therapy, he believes. Given the success he has seen with his first eight volunteers, he says, he's planning to expand his research to a new study group.

Copyright 2016 NPR. To see more, visit NPR.
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Social Security Data Errors Can Turn People Into The Living Dead

NPR Health Blog - Wed, 08/10/2016 - 5:01pm
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August 10, 20165:01 PM ET Heard on Morning Edition

Bad data in means bad data out.

Gary Waters/Ikon Images/Getty Images

A few months ago, when Dr. Thomas Lee logged in to his patients' electronic medical records to renew a prescription, something unexpected popped up. It was a notice that one of them had died.

Lee, a primary care doctor at Brigham and Women's Hospital in Boston, was scheduled to see the patient in three days.

"I was horrified," he says. The patient had been in his 80s, and his wife had died a few months before. "And everyone in medicine knows that when someone dies, there's an increase in risk of death for their spouse over the next six months."

He wanted to know what had happened, but he couldn't find anything in the medical records or in a Web search. "I just felt really guilty that I had not pushed harder to get him in sooner," says Lee. When he couldn't find out anything, he decided to phone the man's house to offer condolences — maybe even to apologize.

"So I called, and to my shock he answered," says Lee. It was the patient, a retired professor living in Boston.

"I assume you're calling about my death," the man said.

"It gave me goose bumps," says Lee. "I said, 'Yeah, I guess I am.' And then he explained to me what had happened."

The professor explained that he'd been dealing with his own death for the past two weeks. It all started when he went to the ATM, only to find that he no longer had access to his bank account. When he went to the pharmacy to pick up his medicine, he found he no longer had health insurance.

Soon after, he got a letter in the mail from the Social Security Administration offering condolences about his recent loss of life and informing him that his monthly payments would end and that payments made since his "death" a few months prior would be removed from his bank account.

Because of a clerical error, the Social Security Administration believed he had died in December. That information had quickly spread to banks, pharmacies, hospitals. His doctor's appointments had been wiped out and other patients had taken his place. Essentially, he'd been locked out of his life.

"It was a major nuisance, let's put it that way," he says. And to add insult to death, says the professor, "Social Security actually gave my date of death as the same date as my wife's, which was really creepy. Not pleasant to see."

He spent weeks on the phone trying to correct it all. In the process (which was reminiscent of a certain Monty Python skit), the man learned that because he had supposedly died, all his information — his full name, Social Security number, birthday and supposed death date — had been released to the public in a document called the Death Master File.

Author Interviews 3 Steps To Faking Your Own Death From The Author Of 'Playing Dead'

The publication of the file is a measure taken to prevent fraud, such as someone taking out a credit card in a deceased person's name. But for those who are still living, the file is a recipe for identity theft. (That's why we're not naming the man.)

"I'm keeping an eye out fairly carefully to see if anything goes awry," he says. "But it's also somewhat amusing to know that you really are alive when everybody thinks you're dead." He even got a hug from a surprised doctor who didn't expect him to show up for his canceled appointment, let alone in relatively good health.

It took about two months to resurrect him in the federal system.

And as Lee wrote this week in the New England Journal of Medicine, what happened to the professor happens to thousands of people each year.

"When we called the information system folks to bring him back to life, the response that we got was, 'Oh no! Not another one,' " says Lee. There's even a frequently asked question about it on the Social Security Administration's website.

"And this is where I made the transition from thinking about this as something funny to something important," says Lee. "We have a society where information travels quickly and there are many great things about it, but what if that information is wrong? There just is no process in most information systems for saying 'Oops, we were wrong.' "

In 2011, an audit found that about 1,000 people a month in the U.S. were marked deceased when they were very much alive. Rona Lawson, who works in the Office of the Inspector General at the Social Security Administration, says that number has gone down. It's now around 500 people a month.

"But for those 500 people, it's still a big impact on their lives, so we'd like to see the number even lower," she says. Because most of them are Social Security clients, she says, they likely tend to be retired and over the age of 60.

Lawson says 90 percent of the time, the cascade of misinformation starts with an input error by Social Security staff — a regular mistake on a regular office day that just happens to kill a person off, at least on paper.

And she says the professor's case, where someone is given the death date of their spouse, is fairly common.

"Oh, yes," says Lawson. "That was a very common cause for the errors that we saw."

In 2011, Congress passed legislation to remove a few pieces of information from the Death Master File – the state, county and ZIP code where a person lives or lived. And in 2013, based on recommendations by Lawson and her colleagues, Congress passed another piece of legislation to keep a person's information from becoming public until 3 years after their death date. The change will kick in in late November.

"So, that's an improvement — more time to get it right before it gets into the public domain and starts spreading to all the different websites and so forth," says Lawson.

She says the information would still go to authorized users like banks and credit reporting agencies, so while the change might keep back identity thieves, it wouldn't do much to prevent the headache that the retired academic went through.

"At least we can keep the information restricted to those who have a right to know it and not just everybody that has an Internet access point," says Lawson.

But wait a minute. Putting aside the headache of having to convince everyone you're still alive just so you can withdraw cash from an ATM, or pick up your prescriptions, might a fake death be seen as an opportunity? Maybe to disappear to a tropical island and start a new life?

"I never thought of that," says the professor. "But that might have been an interesting way to proceed."

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Hikes In Employees' Health Premiums To Outpace Raises Again

NPR Health Blog - Wed, 08/10/2016 - 11:03am
Imagezoo/Getty Images

Large employers expect health costs to continue rising by about 6 percent in 2017, a moderate increase compared with historical trends that nevertheless far outpaces growth in the economy, two new surveys show.

"These cost increases, while stable, are both unsustainable and unacceptable," said Brian Marcotte, CEO of the National Business Group on Health, a coalition of very large employers that got responses from 133 companies.

Employers are changing tactics to address the cost trend, slowing the shift to worker cost sharing and instead offering video or telephone links to doctors, scrutinizing costs of specialty drugs and steering patients to hospitals with records of lower costs and better results.

Most employees at large companies should expect a 5 percent increase in their premiums next year and, in contrast to previous years, "minimal changes" to plan designs, NBGH said.

The portion of employers offering high-deductible health plans next year — 84 percent — is essentially unchanged from 2016, according to the NBGH report. So is the percentage of companies offering high-deductible plans — 35 percent — as the only choice for workers and families.

Patients with high-deductible coverage pay thousands of dollars in medical costs before the insurance kicks in.

The idea is that sharing the pain makes employees smarter shoppers, prompting them to forgo unneeded tests and find the best price. But critics say available tools to shop for care are grossly inadequate.

Counting cost-control measures, companies responding to NBGH's survey expect their net health expenses to rise by 5 percent next year. A survey of hundreds of employers by consultants Willis Towers Watson showed similar results.

"This is well above the cost-of-living increase," said Julie Stone, health care practice leader at Willis Towers Watson. To control costs, "our clients are willing to do things that a few years ago employers might have been reluctant to do," she said.

For what it's worth, 5 percent or 6 percent is moderate compared with medical-cost growth in the early 2000s, when annual percentage increases reached double digits.

But it's still far greater than recent increases in corporate profits and economic output. And it's greater than the 3 percent increases in workers' pay that many groups expect for 2017.

Economists partly blame the skimpy raises workers have received over the past decade on the ballooning resources employers had to devote to health spending.

Moderate cost trends in the large-employer market seemingly contrast with those in the Affordable Care Act's online marketplaces, where plans sold to individuals are seeking premium increases of 10 percent or more.

But the variation has more to do with volatility in how insurance companies price their plans than with big differences in underlying costs, said Larry Levitt, a senior vice president with the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Many marketplace plans underestimated costs for their members this year, forcing catch-up increases for 2017, he said.

New kinds of spending are driving health cost increases.

Even as hospital use has moderated, employers point to specialty drugs to fight cancer or hepatitis C that can cost tens or hundreds of thousands of dollars per patient as a new major contributor to health expense.

Nearly 1 in 3 companies said specialty drugs are the main factor in cost increases, according to the NBGH survey. Nine of 10 employers plan to install programs to manage specialty-drug costs, according to the Willis Towers Watson study.

Approaches include shifting drug coverage to large pharmacy benefit firms, which can deploy better buying power against the manufacturers, and infusing drugs at patients' homes rather than in expensive hospitals, Stone said.

Employers are increasingly steering workers toward hospitals with records of higher quality results and fewer complications for expensive procedures such as fertility treatments and bariatric surgery. Until now companies have promoted such "centers of excellence" mainly for organ transplants.

They're also encouraging remotely delivered preventive care by offering nurse coaches for the chronically ill via telephone and video conferencing to extend the hours of primary care clinicians.

Nine out of 10 large employers will offer such telehealth services next year in states that allow it, up from 70 percent this year, the NBGH survey shows.

Employers continue to shrink coverage for workers' spouses, especially if spouses have access to a medical plan through their own workplace.

By 2018 Willis Towers Watson expects nearly half of large companies to charge an extra $100 or so a month to carry a working spouse on the plan — in addition to the regular premium contributions.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. You can follow Jay Hancock on Twitter: @jayhancock1.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Puerto Rico's Efforts To Stop Zika Are Hampered By Mistrust

NPR Health Blog - Wed, 08/10/2016 - 5:03am
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August 10, 20165:03 AM ET Heard on Morning Edition

A city worker in San Juan, Puerto Rico, cleans up a vacant lot where mosquitoes could be breeding.

Jason Beaubien/NPR

Puerto Rico is in the midst of one of the worst Zika outbreaks of any region in the northern hemisphere. The island has been reporting roughly 1,500 new cases of Zika each week. Hundreds of pregnant women are already infected, and public health officials say the outbreak in Puerto Rico probably won't start to subside until September or October.

Yet health officials also say efforts to stop the spread of the virus are being hampered by mistrust, indifference and fatigue among residents, over what some view as just the latest tropical disease to hit the island.

At a park in the San Jose section of San Juan, 58-year-old Umberto Antonio Guzman leans against a chain-link fence watching baseball practice.

It's just after sunset, but the tropical air is still hot and sticky.

Guzman says he knows about Zika, and adds that he should be worried about it — but he's not. He says this outbreak isn't as bad as when Puerto Rico got hit in 2014 by chikungunya, another tropical disease new to the island.

"The chikungunya was very strong," Guzman says. "A lot stronger than Zika. With Zika many people don't even have any symptoms."

Just a few weeks ago, Guzman's 15-year-old son, who's out on the baseball field playing third base, had a bad case of dengue fever.

Guzman shrugs and says Zika is just one more health problem people here have to deal with.

Puerto Rico had its first Zika case in December of last year. Since then, laboratories have confirmed nearly 9,000 more cases in the commonwealth and U.S. territory.

Health officials say the actual number of people who have contracted the virus is much higher. One sign that's true is that almost 2 percent of blood donations in Puerto Rico are now turning up positive for Zika.

The Centers for Disease Control and Prevention predicts that by the end of the year more than 20 percent of the entire population — or some 700,000 people in Puerto Rico — could be exposed to the virus.

"Among us scientists, it is scary," says Brenda Rivera Garcia, the state epidemiologist for Puerto Rico. She says this is the first time she's ever seen a mosquito-borne virus that's capable of crossing the placenta and causing major birth defects. In extreme cases, the virus is being linked to microcephaly in newborns. And then, as if all that wasn't bad enough, she says, Zika also turns out to be a sexually transmitted disease.

"This is something you would imagine if you were writing science fiction — but it's the reality," Rivera Garcia says. Even though, in some cases, the Zika virus causes only mild symptoms, or none at all, she says, it's clear that's not true for everyone. "We know that there are serious consequences for some in our population."

Yet it's difficult to get many people in Puerto Rico to pay attention to the risks, she and others working to curb the damage say.

A mural in the Puerta de Tierra section of San Juan warns about Zika.

Jason Beaubien/NPR

"Zika is a problem and we are aware of it," says Hiram Torres Montalvo, a public interest lawyer and the co-founder of Puerto Rico Limpio, a citizens' action group that aims to clean up environmental hazards in Puerto Rico. Torres has been trying to raise awareness about mosquitoes spawning in open landfills. But he says sometimes people in the commonwealth just don't have time to think about Zika.

"We have so many problems in Puerto Rico," Torres Montalvo says. "Our economy is bad. We have a lot of crime, a lot of social issues, public debt, problems with the government. I think that we are so overwhelmed by all the problems that we have in Puerto Rico, that maybe we don't pay as much attention as we should to the Zika situation."

One thing that did get a lot of attention recently, in regards to Zika, was a plan backed by the CDC for aerial spraying of insecticide to combat the virus. Residents were furious. The mayor of San Juan, Puerto Rico, called it "environmental terror," and the governor eventually blocked it.

Ralph Rivera Gutierrez, dean of the graduate school of public health at the University of Puerto Rico, is still irate about the proposed aerial spraying.

"To go and spray the entire country, based on the limited scientific evidence of the association [between Zika and microcephaly] — that is outrageous to us," Rivera Gutierrez says.

He's speaking with me at a community cleanup event in the Puerta de Tierra section of San Juan that is aimed at thwarting Zika. Volunteers and municipal workers are clearing out trash from a vacant lot to try to get rid of mosquito breeding grounds.

I ask Rivera Gutierrez if he sees Zika as a major problem for Puerto Rico. "Major?" he answers, and ponders the term. He looks skeptical. "I'll say it is a problem," he says.

Gutierrez says the government is Washington wants to "spray us." That phrase — "spray us" — is repeated a lot in Puerto Rico by opponents to the aerial spraying plan. Residents' response to Zika and their resistance to aerial spraying should be seen within a political context, he says, in which many Puerto Ricans distrust the U.S. government.

"We are an invaded country," Gutierrez says. "We've been a colony of the U.S. for 118 years, and there's been a lot of experimentation done on us. And so people have had enough of that."

The pesticide that was going to be sprayed — Naled — is an organophosphate that has been used in Puerto Rico in the past during dengue outbreaks. Also, Naled is currently being sprayed in Miami-Dade County, Fla., to try to address the spread of Zika there. Rivera Gutierrez points out correctly, however, that Naled is no longer approved for use in the European Union. And, he says, in the case of Zika, the proposal to spray the insecticide in Puerto Rico was an overreaction.

"We don't understand it, except for what might be some economic interest in getting rid of that product," Rivera Gutierrez says.

Amid the heat, the heavy summer rains and the skepticism in Puerto Rico, the Zika virus continues to spread — making people sick and possibly harming hundreds of babies who will be born in the months to come

Copyright 2016 NPR. To see more, visit NPR.
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Olympic Athletes Still Use Some Rx Drugs As A Path To 'Legal Doping'

NPR Health Blog - Wed, 08/10/2016 - 4:42am
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August 10, 20164:42 AM ET Heard on Morning Edition

Russian tennis star Maria Sharapova isn't competing at the 2016 Olympics. At a March 7 press conference in Los Angeles, she told reporters she'd tested positive for meldonium, a prescription heart drug that improves blood flow. It was banned in January by the World Anti-Doping Agency.

Robyn Beck/AFP/Getty Images

When tennis star Maria Sharapova admitted in March to having taken the heart drug meldonium, the public got a rare glimpse of a common practice that's often called "legal doping."

It involves taking a legal prescription drug that may improve performance but hasn't been banned by anti-doping authorities. And lots of athletes competing in the Rio Olympics will be taking advantage of this loophole, doping experts say.

"If it's not banned, athletes will use it," says Ronald Evans, director of the Gene Expression Laboratory at the Salk Institute and an investigator for the Howard Hughes Medical Institute.

Meldonium, which can improve blood flow, was banned by the World Anti-Doping Agency (WADA) in January. So Sharapova's admission in March means she's not eligible to compete in Rio.

But the games are including many other athletes who took meldonium before the ban. The sports they're competing in include tennis, swimming, running, cycling, rugby, rowing and even volleyball.

Since the ban, evidence of meldonium use has been found in tests of more than 100 athletes, according to WADA. But most of these athletes can still compete in the Olympics because levels of the drug were low enough that they might be left over from use that took place before the ban took effect.

Meldonium is just one of a group of prescription heart drugs that could help an endurance athlete gain an edge by improving blood flow, Evans says. "You improve blood flow, you improve oxygen getting to the muscles that you want," he says. "Therefore, it's good for performance."

Meldonium was developed by a drug company in Latvia and has been available since the 1980s. Sharapova reports that she had been taking it for a decade before the ban. And a study of meldonium use at the 2015 European Games in Baku found the drug was used by athletes competing in 15 of 21 sports there.

It's not clear how much advantage those athletes got from meldonium, says Don Catlin, an emeritus professor at UCLA who once ran the university's Olympic Analytical Laboratory. "I'm not convinced at all that it enhances human performance," Catlin says.

But it is clear, he says, that athletes are experimenting with an ever-widening range of prescription drugs in an effort to get an edge.

"All the easy ones have been found," Catlin adds.

One of those drugs is telmisartan, which is marketed as a blood pressure medication.

Like meldonium, telmisartan can improve blood flow. And in 2015, WADA added it to a short list of drugs the agency is monitoring. But telmisartan is not yet prohibited by the group. And that means that, as an athlete, "you almost have to seriously consider using it," Evans says.

Still, meldonium and telmisartan are far from ideal doping agents, Evans says. What athletes really want, he says, is the kind of drug he's been working on for years: "a drug that promotes the benefits of fitness without actually training."

Evans isn't trying to help dopers. He's trying to develop a drug that could save the lives of millions of people with health problems like obesity and diabetes. But he knows that any prescription drug that comes from his work will find its way into competitive sports.

"I get emails from athletes, coaches — the horse racing industry," he says.

That's been true since 2007, when Evans described a compound called AICAR that could dramatically improve the athletic performance of lab rodents. Because of safety issues, it never became an approved drug. Even so, athletes began using AICAR and it was banned by WADA in 2011.

Athletes aren't the only people monitoring drug development. So are the agencies charged with preventing doping.

"Over the last few years, there are more and more [new] medicines [that] might be performance enhancing," says Olivier de Hon, manager of scientific affairs for the Anti-Doping Authority in the Netherlands.

It can take years to assess a potential new doping drug, de Hon says, in part because it can be hard to find information on the performance-enhancing qualities of a substance.

"Most of the scientific literature that's available about meldonium [is] in Russian, and I cannot read that," he says. "So I had some problems in making up my mind what we should do."

Also, simply banning lots of drugs and testing for them is not going to prevent doping, de Hon says. It often comes down to the cultural values of a particular country or a particular sport.

Take cycling for example, a sport where doping has been rampant.

"Within the world of cycling, they realized at one point that this is not the sport anymore that they can sell to the public" or to sponsors, de Hon says.

These days, doping appears to be less common in cycling, he says. But that's because the sport has changed, not because there's more testing for more drugs.

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Young Inventors Work On Secret Proteins To Thwart Antibiotic-Resistant Bacteria

NPR Health Blog - Tue, 08/09/2016 - 3:37pm
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August 9, 20163:37 PM ET Heard on All Things Considered

Christian Choe, Zach Rosenthal, and Maria Filsinger Interrante, who call themselves Team Lyseia, strategize about experiments to test their new antibiotics.

Linda A. Cicero/Stanford News /Courtesy of Stanford University

Three college-age scientists think they know how to solve a huge problem facing medicine. They think they've found a way to overcome antibiotic resistance.

Many of the most powerful antibiotics have lost their efficacy against dangerous bacteria, so finding new antibiotics is a priority.

It's too soon to say for sure if the young researchers are right, but if gumption and enthusiasm count for anything, they stand a fighting chance.

I met Zach Rosenthal, Christian Choe and Maria Filsinger Interrante in the lower level of the Shriram Center for Bioengineering & Chemical Engineering on the campus of Stanford University.

Filsinger Interrante just graduated from Stanford and is now in an M.D./Ph.D. program. Rosenthal and Choe are rising seniors.

Last October, Stanford launched a competition for students interested in developing solutions for big problems in health care. Not just theoretical solutions, but practical, patentable solutions that could lead to real products.

The three young scientists thought they had figured out a way to make a set of proteins that would kill antibiotic resistant bacteria.

They convinced a jury of Stanford faculty, biotech types and investors that they were onto something, and got $10,000 to develop their idea.

"And we want to see if our proteins are more effective at killing these resistant bacteria than what's currently available," says Filsinger Interrante.

Choe says there's a reason industry hasn't solved the antibiotic crisis.

Christian Choe seals a plate with E. coli bacteria that contain a ring of genetic material to produce the antibiotic protein.

Linda A. Cicero/Stanford News /Courtesy of Stanford University

"Big pharmaceutical companies aren't that interested in pursuing antibiotics," he says, "largely because the market size is small, and because bacteria develop resistance relatively quickly."

But these young entrepreneurs think they've licked the resistance problem.

"The way that our proteins operate, that if the bacteria evolve resistance to them, actually the bacteria can no longer live anymore," says Rosenthal. "We target something that's essential to bacterial survival."

Bacteria have managed to evolve a way around even the most sophisticated attempts to kill them, so I was curious to know more about how the proteins these young inventors say they've found worked.

"We're not able to disclose, unfortunately," says Filsinger Interrante. It's their intellectual property, she explains, that they hope will attract investors. "We think that our protein has the potential to target very dangerous, multidrug-resistant bacteria."

"I've been working in the field of antibiotics for the past 25 years and this is as good as any an idea as I've heard," says Chaitan Khosla, a professor of chemical engineering and chemistry at Stanford. He's also the director of a new program called ChEM-H, for Chemistry, Engineering & Medicine for Human Health, that's supporting the students' hunt for a new antibiotic.

But Khosla warns that many good ideas fall by the wayside, and even if the team's proteins clear the initial hurdles, it would be years or decades before there's a product ready to bring to market.

The trio are aware of the long odds. But for now, Rosenthal says they're going to give it all they've got, even it means working late into the night, after classes and other commitments are finished.

"I lose some sleep, but I love what I'm doing, so it's worth it," he says.

The team reports preliminary results for their new antibiotic proteins are looking good, so all that work may be paying off.

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Hospital Units Tailored To Older Patients Can Help Prevent Decline

NPR Health Blog - Tue, 08/09/2016 - 2:13pm
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August 9, 20162:13 PM ET Heard on All Things Considered


Nurse specialist Annelie Nilsson checks on patient Janet Prochazka during her stay at the Zuckerberg San Francisco General Hospital, after Prochazka took a bad fall in March.

Heidi de Marco/Kaiser Health News

Until March of this year, Janet Prochazka was active and outspoken, living by herself and working as a special education tutor. Then a bad fall landed her in the Zuckerberg San Francisco General Hospital.

Doctors cared for her wounds and treated her pneumonia, but Prochazka, who is 75, didn't sleep or eat well in the hospital, and she became confused and agitated. Then she contracted a serious stomach infection.

Patients over 65 tend to be less resilient during a hospital stint than younger patients, research finds, and more vulnerable to mental or physical deterioration, even if they recover from the illness or injury that sent them there. One study published in 2011 found that about a third of patients older than 70 and more than half of patients over 85 left the hospital more disabled than when they arrived.

As a result, many previously independent seniors are unable to care for themselves after discharge and need assistance with daily activities such as bathing, dressing or even walking.

"The older you are, the worse the hospital is for you," says Dr. Ken Covinsky, a physician and researcher at the University of California, San Francisco's division of geriatrics. "A lot of the stuff we do in medicine does more harm than good. And sometimes with the care of older people, less is more."

As hospital staffs focus on treating the acute injury or illness, they may fail to ensure that older patients get adequate nutrition, he says, or fail to get them out of bed enough or control their pain adequately.

Hospital patients are often inadvertently restricted in their movements because of tethers to oxygen tanks and IV poles. They are subjected to various procedures and medications, and are often in noisy rooms, where careful monitoring means checking their vital signs at all hours of the night.

Ron Schwarz, 79, was hospitalized after falling in the shower. He spent time healing at the Acute Care for Elders unit at San Francisco General, one of about 200 such units nationwide.

Heidi de Marco/Kaiser Health News

And if the drug side-effects, interrupted sleep, unappetizing food and long days in bed are annoying when we're young, they can cause lasting damage as we get older, Covinsky says. Studies find that elderly patients often process medications differently than younger people, for example, and frequently have multiple medical problems, not just one.

Their needs are particular enough that some hospitals have established separate medical units to treat elderly patients.

San Francisco General is one such hospital. Its Acute Care for Elders ward, which opened in 2007, is staffed by a health team trained in geriatrics. They focus less on the original diagnosis and more on how to get patients back home, living as independently as possible.

Early on, for example, the staff tests patients' memory and assesses how well they can walk and care for themselves at home. Patients are also encouraged from the start to do things for themselves as much as they are able throughout their stay. The health team removes catheters and IV tethers as soon as medically advisable, and supports patients in getting out of bed and eating in a communal dining area.

"Bed rest is really, really bad," says the unit's medical director, Dr. Edgar Pierluissi. "It sets off an explosive chain of events that are very detrimental to people's health."

Such units are still rare — there are only about 200 around the country. And even where they exist, not every elderly patient is admitted, in part because space is limited.

Prochazka initially went to the emergency room and was admitted to the intensive care unit from there. She was transferred to ACE about a week later.

Though the move to the specialized unit helped Prochazka, her doctor says, it couldn't completely restore her former health.

"She will not leave here where she started," Pierluissi said several days before Prochazka was discharged. "She is going to be weaker and unable to do the things you really need to do to live independently."

Still, the unit's staff — a team that includes a doctor, a nurse, a pharmacist and a social worker — came up with a plan specifically for Prochazka's needs that helped her heal. They weaned her off some of her medications. They got her up and walking. They also limited the disorienting nighttime checks.

Prochazka says that, once on the unit, she got "the first good night of sleep I have had." Ultimately, she was able to return home, and her health has continued to improve as she slowly regains strength.

How hospitals handle the old and very old is a pressing problem, geriatricians say. Nearly 13 million seniors are hospitalized each year — a trend that will only accelerate as baby boomers age.

Yet hospitals face few consequences if elderly patients become more impaired or less functional during their stay, Covinsky points out. The federal government penalizes hospitals when patients fall, get preventable infections, or return to the hospital within 30 days of their discharge, but the institutions aren't held accountable if patients lose their memory while there or become so weak they can't walk. As a result, most hospitals don't measure those things.

"If you don't measure it, you can't fix it," Covinsky says. The extra investment needed to create specialized units would pay off in the long run, he believes — for patients, hospitals and for the U.S., as it works to bring down health care spending.

ACE units have been shown to reduce hospital-inflicted disabilities in older patients, decrease lengths of stay and reduce the number of patients discharged to nursing homes. In one 2012 study published in the journal Health Affairs, researchers found that hospital units for the elderly saved about $1,000 per patient visit.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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How The Microbes Inside Us Went From Enemies To Purported Superhealers

NPR Health Blog - Tue, 08/09/2016 - 11:22am

Colored scanning electron micrograph (SEM) of Escherichia coli bacteria (green) taken from the small intestine of a child. E. coli are rod-shaped bacteria that are part of the normal flora of the human gut.

Stephanie Schuller/Science Source

"Microbes have always ruled the planet but for the first time in history, they are fashionable," writes Ed Yong in his new book, I Contain Multitudes: The Microbes Within Us and a Grander View of Life, on sale Tuesday.

Yong, a U.K.-based science writer, describes how humans ignored, feared and then lauded the "microscopic menagerie" living inside us and other animals. He explains how these resident bacteria, fungi, archaea and viruses, known collectively as the microbiome, form intimate partnerships with their hosts — contributing to everything from the glow of a squid's light organ to the development of our own immune systems.

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Scientists are testing whether microbes (especially bacteria) have the potential to treat asthma, allergies, obesity and a range of hard-to-treat infections. But Yong questions whether our growing enthusiasm for these microbes has outstripped the scientific evidence.

We spoke with Yong about what the latest science says about microbes and human health.

The interview has been edited for length and clarity.

Interview Highlights

Does what we eat influence our microbial residents?

There've been many studies showing that when people change their diet, the microbes in their guts also change. And of course they do. If you think of adding a different set of nutrients into an ecosystem, of course it's going to affect the number and range of species in that place. The critical questions are what kinds of changes are good or bad for health and how can we enact those changes through taking steps in our diet. These are still pretty open questions.

It seems that dietary fiber is a really important driver of microbial diversity in our bodies. Fiber consists of large numbers of different carbohydrates — many we can't digest, but our bacteria in our guts can. If we eat low-fiber diets, we narrow the range of our microbial partners. But the guidance to eat more fiber has been a longstanding part of nutritional advice. The discoveries of the microbiome lend credence to that, but don't fundamentally change it.

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What about how food influences a baby's developing microbiome?

There is a particular subspecies of bacteria called B. infantis and it seems to have evolved to feed on sugars [in breast milk] known as human milk oligosaccharides. Babies can't digest [the sugars] so they are food for the microbes, not for the babies. These sugars are sort of a way of setting up a baby's first microbiome, ensuring that the right species set up shop rather than those that are likely to cause disease. And it's fascinating to me to think of this very common act, breastfeeding, through this new microbial lens.

Should we be worried that some of the microbes that have been living inside us for thousands of years are becoming scarce?

Many of the trappings of Western civilization have led to a decline in the microbiome — like hand sanitizers, antibiotics, excessive hygiene, changes in diet. A lot of data support this idea, but it's still not clear whether the fall in diversity is a bad thing. What we know is that the diversity of the gut microbiome is much higher in apes than it is in hunter-gatherers and then much higher in hunter-gatherers than in Westerners. So this decline is part of a trend that has been going on for some time and precedes humans. So does it just reflect changes in evolution and diet? And, if so, to what extent is it actually causing us health problems?

What's the evidence behind fecal transplants for treating human illnesses?

The results are very clear for treating infections of Clostridium difficile, a very hardy bacterium that causes recurrent and often intractable cases of diarrhea. Fecal transplants have been used to treat this condition many times over in many countries. It's been tested in randomized controlled studies, which is the gold standard. The first trial had to be stopped early because [the transplants were so successful that] it seemed unethical to not put all of the patients on this treatment.

Author Ed Yong

Urszula Sołtys/Courtesy of Ecco

That said, the results for other conditions like irritable bowel syndrome and inflammatory bowel disease have been far more inconsistent. That's because C. diff. is kind of a special case. It's a very invasive microbe that has repeatedly been assaulted by antibiotics which have caused a collapse in other microbes. So it's an easy environment for [microbes in] a donor stool to invade.

It might just be that C. diff. was the low hanging fruit. That said, fecal transplants are arguably our most successful microbiome-based therapy. They show some important principles that we might like to take heed of like the fact that [the treatment] is a community-based approach. There are lots of questions to be answered. [For example], we don't know what the long-term risks are, if any.

It seems like there are a lot of questions remaining about how our microbiomes affect our health. Why don't we have more answers yet?

The way I see it, there are many areas in medicine where the math is simple. Say you have a vitamin deficiency, you add a vitamin and then you're better. With manipulating the microbiome, it is infinitely more complicated because this is an entire world — a community of hundreds if not thousands of microbes interacting with each other and us, their hosts.

Tweaking that is understandably very hard. It's why simple measures like probiotics — adding a few strains of microbes in the hope that they will take hold and remedy health problems — have been largely unsuccessful. It will take more. It will take an understanding of how different microbes interact, whether they feed each other or compete with each other. If we want to add microbes to our bodies, we'll need to think about whether we need to eat certain foods to nourish the microbes we're taking.

Our microbiomes are constantly changing, day by day, hour by hour. It's the flexibility that has people so excited because you should be able to change it so easily — certainly easier than genes. But ecosystems have resilience. You can nudge them and they bounce back.

Copyright 2016 NPR. To see more, visit NPR.
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WATCH: Lessons In Wound Healing From Our Favorite Fly

NPR Health Blog - Tue, 08/09/2016 - 9:01am

The underwater construction skills of the caddis fly larva have caught the interest of bioengineers. The larva tapes and glues pebbles together to form a sturdy protective case.

Josh Cassidy/KQED

Instead of stitches and screws, doctors are looking to the next generation of medical adhesives — glues and tape — to patch us up. Their inspiration? Water-loving creatures like oysters, marine worms and the caddis fly, a type of stream-dwelling, fish-baiting insect that lives in creeks all across the United States.

The medical adhesives doctors use today work pretty well outside the body. Attach a "waterproof" bandage to dry skin, and it will stay put, for a time. And certain brands of liquid stickum, such as Super Glue and Krazy Glue, which employ compounds called cyanoacrylates, also resist degradation in water.

The challenge for mechanical engineers, however, is making compounds that will stick to things when they're already submerged.

"Typically we can make an adhesive bond that is stable underwater," says Nicholas Ashton, a doctoral student in bioengineering at the University of Utah. "But we can't form the bond underwater."

Humans are 60 percent water, and our insides are as fluid as fish tanks — hostile to chemical adhesives. So, doctors have traditionally used mechanical means to mend bones and sew up internal tissues.

"The second you go inside the body, it changes the ballgame entirely," says Ashton.

Enter the caddis fly, a stream-dwelling insect equipped with a homespun waterproof tape dispenser. In its larval stage, this industrious builder uses pebbles and its double-sided "tape" to construct a tiny, tube-like house, or "case," for itself — entirely underwater. The tape is really a specialized silk, extruded by a pair of glands under its chin.

Deep Look/KQED YouTube

Thanks to the qualities of that silk, the case not only holds up underwater, it is strong enough to protect the caddis fly's soft lower body amid forces many times its body weight.

"It's an extremely fancy tape," says Russell Stewart, a materials science engineer at the University of Utah, who studies caddis fly silk.

The case-building behavior begins as soon as the caddis flies hatch.

"And when they get to building, they are very selective," says Patina Mendez, an environmental entomologist at the University of California, Berkeley.

After carefully choosing a starter pebble (called a ballast stone) for its case, the caddis fly meticulously tapes stone after stone together, as the case begins to take shape.

California is home to approximately 400 species of caddis flies, and there are some 15,000 worldwide, all of which use some version of the silk.

A caddis fly larva doesn't need its sticky tape to perch on a human finger.

Josh Cassidy/KQED

Any tape, including this one, has two basic components, scientists explain: the flat ribbon, or backing, and the layer of sticky stuff, or glue. From the standpoint of materials science, caddis fly tape is extraordinary in both departments.

Though its mechanism still isn't fully understood, the sticky part of the tape forms highly complex bonds, both chemical and physical, with whatever it adheres to. As these bonds form, they displace the water where the tape meets the stone, allowing the two substances to stick together.

Interestingly, unlike most glues, which tend to work better on clean, dry surfaces (like skin), the glue of the caddis fly bonds more readily to biofouled surfaces — those already coated with decaying matter and bacteria from the stream.

The scientists say this fly's adhesive system is distinct from that of other well-studied underwater glue-makers, such as mussels and sea cucumbers, and may offer a very different path forward for researchers trying to engineer an underwater fixative.

As for the ribbon component of caddis fly silk, it's resilient — like a rubber band. The fiber can stretch to twice its original length and still recover. But unlike a rubber band, caddis fly silk returns to its shape slowly. The tape fibers can absorb forces that would cause another material to snap back violently, Stewart says.

The pebbles of its case stay snugly in place, as the larva weathers steep climbs underwater.

Josh Cassidy/KQED

Given the larva's challenging environment, that type of mortar makes its pebble case resilient, too. Stewart uses an earthquake analogy: "If you think about a house made out of brick or stone, it's brittle," he explains. "You don't want to live in a stone house in California! If you have an earthquake, it would break and fall down. But if the mortar were flexible, it wouldn't."

Compare that resilience to spider silk which, though mechanically stronger, isn't built to last. If an insect damages a spider's web, the spider has to make all new threads. (Spider silk also loses its remarkable elasticity altogether underwater.)

The ability to mimic caddis fly silk is only in its infancy. With the help of chemical models, Stewart and his colleagues have been able to reverse-engineer a primitive version of the glue component that went on wet in a watery setting, then solidified without losing integrity. One day, a similar compound might be used inside the body to mend soft tissues, like organs and tendons, and even repair hard ones — like teeth and bone.

Eventually, the caddis fly larva makes its case into a cocoon by sealing it up at the top with what's called a "hat stone," and reinforcing the inside with extra tape. That's when the insect larvae are most recognizable in the wild, Mendez says, because of their habit of gathering together.

"They line themselves up like little sleeping bags," she says.

Like its land-based cousins, butterflies and moths, from whom it diverged 250 million years ago, the caddis fly larva then undergoes a metamorphosis and emerges as a winged adult.

That's the form that most often captures the imagination of people.

"When I go give a lecture, I always ask, is there a fly-fisherman in the room?" Stewart says. "There usually is."

This post and video were produced by our friends at Deep Look, a wildlife video series from KQED and PBS Digital Studios that explores "the unseen at the very edge of our visible world." Lisa Potter contributed reporting.

Copyright 2016 KQED Public Media. To see more, visit KQED Public Media.
Categories: NPR Blogs

Athletes Go For Gold With Red Spots Blazing

NPR Health Blog - Mon, 08/08/2016 - 4:31pm

Michael Phelps shows signs of cupping on his way to another gold medal in Rio de Janeiro.

Al Bello/Getty Images

Swimmer Michael Phelps won Olympic gold again Sunday while covered in red — red spots, roughly medal-size, all over his shoulders and back.

The marks were the result of an ancient Eastern medicinal therapy known as cupping that is achieving new popularity among some athletes in the United States, including numerous Olympians.

Cupping typically involves treating muscle pain and other ailments with cups that apply suction to skin. Cupping is often combined with other forms of alternative medicine, such as acupuncture and massage.

"The practice itself is very old," says Karyn Farrar, a physical therapist at Rehab 2 Perform in Frederick, Md. "In the past five to 10 years it's becoming prominent in terms of physical therapists, athletic trainers and massage therapists [in the United States] using it more and more." Farrar's office treats five to 10 athletes — mostly high school and college students — with cupping each day.

Farrar says cupping is like a reverse form of massage. Instead of applying pressure downward onto muscles, she says, "you're using negative pressure to pull soft tissues apart" from the suction of the cup. "As you're pulling, you're also getting increased blood flow to the tissues."

She claims the practice decreases swelling in acute injuries and speeds up healing. The large red spots are caused by the bursting of small blood vessels near the skin.

Farrar says she expects more athletes to ask about the treatment after seeing the very visible signs of its aftermath on some of this year's Olympians.

According to Ted Kaptchuk, a professor of medicine at Harvard Medical School who is trained in Asian medicine, the cupping trend isn't exactly new in the U.S. Cupping has a long history in Western medicine and was commonly practiced by American physicians in the 18th and 19th centuries.

But Kaptchuk says cupping fell from favor in the U.S. in the 1920s when practitioners of Western medicine began to see the practice as "old-fashioned," in part because of a lack of scientific evidence that it had a true healing effect.

Today, while some studies have explored the effects of cupping, there is still scant scientific evidence supporting its healing potential.

"We need rigorous research to understand whether there is a physiological effect associated with cupping and currently that is unknown," says David Shurtleff, deputy director of the National Institutes of Health's National Center for Complementary and Integrative Health.

NCCIH currently doesn't fund research on cupping, partly because the studies are challenging to design. It is difficult to know whether a patient feels better after cupping because the treatment worked on a physical level or because the patient expected to feel better and so does — in other words, the placebo effect.

But Shurtleff and Kaptchuk agree that a placebo effect from cupping could work to reduce pain with or without an underlying physical benefit.

While there is still limited scientific evidence supporting cupping, Kaptchuk says that "what we do have, is that people feel better after it's done."

For Olympians, that feeling may be just enough to help them on a trip to the medal podium.

Copyright 2016 NPR. To see more, visit NPR.
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In Boston's 'Safe Space,' Surprising Insights Into Drug Highs

NPR Health Blog - Mon, 08/08/2016 - 3:40pm
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Tommy, a repeat patient at the Supportive Place for Observation and Treatment in Boston, says the room has saved lives.

Jesse Costa/WBUR

Some arrive on their own, worried about what was really in that bag of heroin. Some are carried in, slumped between two friends. Others are lifted off the sidewalk or asphalt of a nearby alley and rolled in a wheelchair to what's known as SPOT, or the Supportive Place for Observation and Treatment, at the Boston Health Care for the Homeless Program.

Nine reclining chairs have been full most days, especially during peak midday hours. It may be the only room in the country where patients can ride out a heroin or other high under medical supervision.

"It's a safe place to be," says Tommy, 39, who's been using heroin for at least 21 years. "It's a lot safer than being out on the street, possibly walking into traffic. I might OD if I was alone out there."

Tommy is looking for a job and housing, and we've agreed not to use his full name. He's one of 180 people who've come to this former conference room to ride out an opioid or other drug high since SPOT opened in late April. Nurses have logged almost 900 visits. At least half of the patients have come more than once.

If the person can speak, a nurse will ask what they took before settling them in a chair, wrapping a blood pressure cuff around one arm and placing an oxygen monitor over a finger.

Shots - Health News Boston's Heroin Users Will Soon Get A Safer Place To Be High

"The monitors are really convenient," Dr. Jessie Gaeta, chief medical officer for BHCHP, says as she pulls the Velcro edges of a blood pressure cuff apart. "It takes a lot of the guessing out of understanding how far someone is into an overdose syndrome."

Gaeta coined the term "overdose syndrome" to describe what's happening to patients in this room. In many cases, she is surprised by what she's seeing.

"A classic opiate overdose is characterized by a person who stops breathing," Gaeta says. "They have central nervous system depression. So it's mostly respiratory depression and respiratory arrest."

But Gaeta says about 75 percent of her SPOT room patients show something different. "What we're seeing in this room is more depression of heart rates and blood pressures as actually the primary — sometimes the only — abnormalities," Gaeta says. So the patient may be unconscious with low blood pressure, but have nearly normal breathing.

Dr. Jessie Gaeta, chief medical officer of the Boston Health Care for the Homeless Program, stands at a setup where heroin users would be monitored while riding out a high.

Jesse Costa/WBUR

Patients tell Gaeta they may start the day with heroin or another opioid and then, a few hours later, take pills that will enhance the high.

"People are talking about that a lot here," Gaeta says, "about the layering of this cocktail of medications, and that's really reflected in the vital signs that we're seeing, which is not indicative of pure opiate overdoses. I'm not sure that we'd have seen that without doing this kind of monitoring."

Gaeta describes a typical combination or cocktail of four drugs: heroin or another opioid, clonidine (which lowers blood pressure), Klonopin (to control for anxiety) and gabapentin (used to treat seizures or nausea).

The observations are just a snapshot based on a small number of addiction patients in one area of Boston. But what Gaeta is seeing is reflected in overdose death reports and is changing the way she and her staff respond to these patients who look like they are falling into a deep sleep. To boost sinking blood pressures, for example, they've brought IV fluid equipment into the room. They are going through many more tanks of oxygen than expected.

Dr. Barbara Herbert, president of the Massachusetts chapter of the American Society of Addiction Medicine, says she's never heard anyone use the term "overdose syndrome."

"But I think it's a great phrase, and I suspect it will move into more conversations. Because we created a safe space, we can now think about what's in front of us with more science than we could before we had this," she says. "So, while all of us knew this cocktail could produce overdose, few of us have ever had the opportunity of seeing people after they use and monitoring their blood pressure or their heart rate. So, this is an unexpected positive for us, coming to understand the disease better from that safe space."

SPOT nurse April Donahue says some patients in the room appear so sedated that they don't respond when she speaks loudly in their ear or raps on their sternum. But, she says, some of those people "have rock-solid vital signs, better than mine." So, she says, "What you see subjectively looking at someone and what their vital signs are don't always match up."

The facility is going through many more tanks of oxygen than expected because of what medical staff are learning about what's going on in the body while people are high.

Jesse Costa/WBUR

If Donahue weren't monitoring the vital signs, she says, she'd be racing to inject naloxone, the drug that reverses the effects of opioids. But Donahue found she can sometimes avoid using naloxone, which is very harsh on the body, by giving patients oxygen or fluids to keep them alive.

The nurses speak to each patient about addiction treatment. Getting patients into treatment is their top priority after keeping people safe while high.

"I think what's struck me the most is the gratitude — just to get out of that environment, even for a little while, to get off the street and be cared for," Donahue says. "I mean, so many of our participants don't have anyone who's caring for them."

It's one reason Tommy is becoming a repeat client. "This is just a great start," Tommy says. "I think it will slow down a lot of overdoses and could save a lot of lives. It will save a lot of lives in the long run."

And Tommy knows. He went into respiratory failure a few weeks ago while at SPOT and was brought back with naloxone.

This story is part of a reporting partnership with NPR, WBUR and Kaiser Health News.

Copyright 2016 WBUR. To see more, visit WBUR.
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Federal Officials Seek To Stop Social Media Abuse Of Nursing Home Residents

NPR Health Blog - Mon, 08/08/2016 - 2:00pm

Editor's note: This story contains language that some may find offensive.

An inspection found that at one Los Angeles nursing home an employee took video of a co-worker "passing gas" on the face of a resident and posted it on Instagram.

Universal Images Group/Getty Images

Federal health regulators have announced plans to crack down on nursing home employees who take demeaning photographs and videos of residents and post them on social media.

The move follows a series of ProPublica reports that have documented abuses in nursing homes and assisted living centers using social media platforms such as Snapchat, Facebook and Instagram. These include photos and videos of residents who were naked, covered in feces or even deceased. They also include images of abuse.

Shots - Health News Social Media Abuse Of Nursing Home Residents Often Goes Unchecked

The Centers for Medicare and Medicaid Services, which oversees nursing homes, said in a memo to state health departments on Friday that they should begin checking to make sure that all nursing homes have policies prohibiting staff from taking demeaning photographs of residents. The memo also calls on state officials to quickly investigate such complaints and report offending workers to state licensing agencies for investigation and possible discipline. State health departments help enforce nursing home rules for the federal government.

"Nursing homes must establish an environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity," said the memo signed by David Wright, director of the CMS survey and certification group. "Treating a nursing home resident in any manner that does not uphold a resident's sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetuates a disrespectful and/or potentially abusive attitude towards the resident(s)."

CMS said that nursing homes have a responsibility to protect residents' privacy, to prohibit abuse, to provide training on how to prevent abuse and to investigate all allegations of abuse. If homes fail to do so, they can face citations, fines and theoretically even termination from the Medicare program.

Also last week, Sen. Charles Grassley, R-Iowa and chairman of the Senate Judiciary Committee, called on other federal agencies to take action on the problem. He sent letters to the Department of Justice and to the Office for Civil Rights within the Department of Health and Human Services asking whether "rules and protections are in place to prevent and punish these types of abuses." He also has sent letters to social media companies, calling on them to pay more attention to this. The Office for Civil Rights is working on its own guidance related to social media but hasn't released it yet.

In a statement to ProPublica, Grassley praised the new CMS memo. "This guidance is welcome and necessary," he wrote. "Nursing homes are obligated under the law to keep their residents free from abuse. Exploitation on social media is a form of abuse, and the agency memo makes that clear. We need to prevent it, and we need to punish it when it happens."

ProPublica has identified 47 instances since 2012 in which workers at nursing homes and assisted-living centers shared photos or videos of residents on social media networks. This includes three discovered in recent weeks. At one Los Angeles nursing home, an employee took video of a co-worker "passing gas" on the face of a resident and posted it on Instagram, according to a May inspection report.

"An interview was conducted with Resident 1 and the resident stated that facility employees pass gas in his face as often as every month," the report said. One employee resigned and a police report was filed.

While some states have taken harsh steps against nursing homes at which social media abuse occurs, other states have not. We reported last month that Iowa health officials recently discovered it wasn't against state law for a nursing home worker to share a photo on Snapchat of a resident covered in feces because his genitals weren't visible. Officials are trying to change the law when the Iowa Legislature reconvenes early next year.

The federal government memo sets uniform standards for how such abuse should be written up by inspectors and the severity of sanctions that should be levied. In the past, there was great variability.

Last month, the industry's trade group issued its own suggestions for dealing with such situations, encouraging training and swift responses by these facilities when allegations are brought to light. The group also is holding training events around the country. While many facilities ban the use or possession of cell phones by employees when in resident areas, some have also found such rules impractical to enforce.

Greg Crist, a spokesman for the American Health Care Association, the trade group, said the CMS memo dovetails with the industry's effort to stop social media abuse.

"The two words in that CMS directive that stand out most to me are 'privacy' and 'responsibility,' " Crist wrote in an email Monday. "That's why we have taken responsibility and made a concerted, nationwide effort to educate and share best practices with our centers not only on how to detect and root out this abuse, but also proactive steps to ensure it doesn't happen in the first place.

"It's not an issue that is conquered overnight," he wrote, "but every day, we get smarter about it."

Has your medical privacy been compromised? Help ProPublica investigate by filling out a short questionnaire. You can also read other stories in our Policing Patient Privacy series.

Copyright 2016 ProPublica. To see more, visit ProPublica.
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